Healthcare Provider Details

I. General information

NPI: 1982164505
Provider Name (Legal Business Name): MS. MELISSA KIYO BROBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12235 BEACH BLVD
STANTON CA
90680-3939
US

IV. Provider business mailing address

16825 PEMBROOK LN
HUNTINGTON BEACH CA
92649-6022
US

V. Phone/Fax

Practice location:
  • Phone: 714-202-0118
  • Fax:
Mailing address:
  • Phone: 714-606-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: